CMS Price Transparency Guidance for Health Plans

As of July 1, 2022 in accordance with the U.S. Government Centers for Medicare and Medicaid Services (CMS) Transparency in Coverage Rule all U.S. health plans are obligated to make public their standard charges online in two formats: In Network Rate File and Allowed Amount File. Both lists are required by CMS and are subject to penalties.

Please find the key points to help health plans verify that their Network Rate File and Allowed Amount files meet all CMS requirements:

	In Network Rate File	Allowed Amount File
GENERAL REQUIREMENTS a complete overview at Subpart B-Public Disclosure Requirements):	Reports payment rates negotiated between plans or insurers and providers for all covered items and services Single comprehensive machine-readable file (please refer to § 54.9815-2715A for further discussion) Name and identifier for each plan option or coverage offered by the plan or issuer Billing codes or other codes used by the plan or issuer to identify items or services The last date of contract term for each provider-specific negotiated rate that provides to each item and service	Reports historical actual billed and allowed amounts for covered items or services incurred by out-of-network providers during the 90 days beginning 180 days prior to the publication date of the file Name and identifier for each plan option or coverage offered by the plan or issuer Billing codes other codes used by the plan or issuer to identify items or services

STANDARD CHARGES The following data points (columns) are required for each charge item:	Negotiated rate – the amount a group health plan or health insurance issuer has contractually agreed to pay the in-network provider, including an in network pharmacy or other prescription drug dispenser Derived amount (if applicable) – relevant when the negotiated rate is something other than fee-for service, such as a bundled payment Underlying fee schedule rate (if applicable) – likely to be relevant when the negotiated rate corresponds with an alternative payment model, such as a capitation. The rate for a covered item or service from a particular in-network provider…that a group health plan or health insurance issuer uses to determine a participant’s or beneficiary’s cost-sharing liability for the item or service, when the rate is different from the negotiated rate or derived amount	Billed Charges – defined as the total charges for an item or service billed to a group health plan or health insurance issuer by a provider Out of network allowed amounts – defined as the maximum amount a group health plan or health insurance issuer will pay for a covered item or service furnished by an out of network provider

Format	All machine-readable files must be made available via HTTPS to ensure the integrity of the data Search engine discoverability needed All files must report information at the place of service (POS), tax identification number (TIN), and nation provider identifier (NPI) Acceptable formats include CSV, JSON, XML, YAML (but not limited to) PDF, XLS/XLSX are NOT considered machine readable formats

Naming Convention	The producers of the file have the option to group multiple plans together with the same negotiated dates (or allowed amounts). If plans are grouped together a table-of-contents is required to capture all the different plan data along with a URL on where to download the appropriate files. For payer or issuer’s names that have spaces, spaces will be replaced with dashes Only alphanumeric characters are allowed. Special characters are to be removed or replaced with dashes The following is the required naming standard for each file: <YYYY-MM-DD___. Multiple plans per file Table-of-contents required The naming standard will be applied to the table-of-contents file and both the in-network and allowed-amounts files will not have any naming standards Naming standard for table-of-contents file __index.

Location of information	Displayed prominently on a publicly available website and in a prominent manner that clearly identifies the health plan’s location with which the information is associated

Access to information	No barriers to access: Free of charge, no account or password required; No Protected Health Information required to access No submission of any Personal Identifying Information

Updates	Monthly – with date of last update clearly indicated FOR ADDITIONAL DETAILS ON THIS REQUIREMENTS REFER TO: 84 FR 65524

Future Requirements	Effective January 1, 2023 group health plans and health insurance issuers will be required to make cost-sharing information available for 500 defined items & services For participants and beneficiaries covered by the health plan Cost-sharing estimates be provided in plain language The list of 500 service include common and “shoppable service” such as office visits, imaging, lab work, cancer screenings, hysterectomies, and knee replacements Estimates must include all forms of cost sharing and be customized to reflect the members accumulation to the deductible and out of pocket maximum Estimates must be provided in real time via the internet and a hard-copy format upon request Effective January 1, 2024 the cost-sharing information requirement expands from the 500 defined items and services to include all covered items and services

Please note, beginning July 1, 2022, CMS will monitor and enforce these price transparency requirements. For health plans that do not comply:

They may be issued a warning notice by CMS

After receiving a warning notice, CMS will request a corrective action plan

CMS may impose a civil monetary penalty up to $100 per day adjusted annually under 45 CFR part 102. For additional details on enforcement refer to 45 CFR part 150.

Resources:

In Network Rate File

Allowed Amount File

GENERAL REQUIREMENTS

STANDARD CHARGES

Format

Naming Convention

Location of information

Access to information

Updates

Future Requirements

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